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1 STRENGTHENING OUTREACH AND ENROLLMENT EFFORTS TO INCREASE HEALTH INSURANCE COVERAGE AMONG MEN OF COLOR IN CONNECTICUT OVERVIEW The Affordable Care Act (ACA) offers an historic opportunity to expand health coverage and address health disparities for people of color through its mandate that states create new health insurance marketplaces that offer affordable coverage to all residents. The ACA also gives states the option of filling gaps in coverage for the poorest Americans by expanding eligibility for their Medicaid programs. In Connecticut, this expanded Medicaid eligibility and enrollment will be coordinated with the new private insurance marketplace: Access Health CT. Black males and other men of color should be a critical target for Access Health CT and new Medicaid coverage because, in Connecticut as in the rest of the nation, this population has historically low rates of health insurance, very poor health outcomes, and higher poverty rates, compared to whites. Nevertheless, enrolling more men of color in health insurance will require targeted, aggressive outreach from trusted sources, effective messaging, and personal assistance in the enrollment process. It will take concerted and coordinated efforts on the part of multiple stakeholders working at multiple levels. The Connecticut Assisters and Navigators Outreach Programs created by Access Health CT and the Connecticut Office of the Healthcare Advocate are a critical component of the work, but their efforts need to be supplemented and supported by many other organizations. This brief discusses some of the challenges and barriers to enrolling men of color in health insurance in Connecticut and offers recommendations for how community-based groups, non-profit service providers, community health centers, and state agencies might address them. It grows out of work that the Aspen Institute Roundtable on Community Change and its local partner, the Mount Aery Development Corporation in Bridgeport, have done under the Health Equity and Leadership (HEAL) initiative over the past two years. HEAL, which was supported by the Connecticut Health Foundation, focused on drawing more attention to health care challenges facing young men of color in Bridgeport, and on promoting greater coordination among the public and civic organizations that most touch their lives.

2 ENROLLMENT CHALLENGES AND BARRIERS FOR MEN OF COLOR Connecticut has been an early adopter of health care reform under the ACA, but faces many obstacles and challenges in its efforts to decrease health disparities and increase health insurance coverage among men of color. Men of color should be a critical focus in Connecticut because here, as in the rest of the nation, they are most likely to have the poorest health outcomes. For example, in Connecticut, black men live almost five years less, on average, than white men. 1 Black and Hispanic men are about twice as likely as white men to have diabetes or cardiovascular disease, and almost three times less likely to go to a doctor because of cost. 2 Men of color are about three times less likely than white men in Connecticut to have health insurance. 3 Providing health insurance is not a cure for all health problems, but it is a critical step in reducing health disparities. Without health insurance, low-income patients are more likely to delay or forgo necessary health care services or seek costlier emergency room care in hospitals. Many men of color currently lack any kind of health insurance, public or private. Many are unemployed or work in low-paying jobs that do not provide employer-funded health insurance. An estimated 88,000 adults in Connecticut will qualify for free public health insurance for the first time through the expanded Medicaid provisions of the ACA. 4 Almost half of the potentially eligible are estimated to be people of color. 5 Even when health insurance is free, it is not always accessed or utilized. Historically, many people do not register for public health insurance, even when they are eligible for it. In Connecticut, an estimated 25,000 adults are currently eligible for Medicaid but not enrolled. 6 Men of color are also more likely to be significantly disadvantaged in other ways that will make participation in the new insurance marketplace challenging. In Connecticut, the percentage of black and Hispanic males living in poverty is 4 to 5 times greater than that of white males. The unemployment rate among African American men in 2011 was twice that of all men. 7 Men of color are also more likely to live in urban neighborhoods that are less healthy and safe. Men of color are also much more likely to be incarcerated. In 2008, 5 percent of African-American men living in Connecticut were in jail or prison, compared to less than one percent of white men. 8 Page 2

3 The percentage of black men in Connecticut without a high school diploma is over three times that of white men; rates among Hispanic men are six times higher. 9 Many individuals in Connecticut are unaware of or misinformed about the provisions of the Affordable Care Act. Many are daunted by the enrollment procedures and the complexity of choosing a health plan, or unsure whether they qualify for free or subsidized health insurance. For men of color, these issues may be compounded by other everyday realities. Many men of color may find it particularly difficult to enroll or may be reluctant to enroll because they: have experienced multiple barriers in accessing health care in the past and/ or are accustomed to seeking health care only in crises or on an emergency basis have had bad past experiences with enrollment and eligibility processes for public benefits have literacy and numeracy problems that make it difficult to manage the enrollment process suffer from mental health or substance abuse problems that can impede their ability to complete the enrollment process and/or maintain their eligibility. Men of color with a mental illness or behavioral health problems (including substance abuse problems) are particularly vulnerable populations who will need enrollment assistance. 10 In Connecticut, about 19 percent of the adults who will newly qualify for Medicaid are estimated to have some mental illness. Estimates are that about a third of those who have a serious mental illness and would qualify for Medicaid coverage under the ACA in Connecticut would be people of color. 11 All of these social factors contribute to health disparities and will make it more difficult for men of color to learn about Access Health CT and new Medicaid coverage opportunities and to complete the complicated insurance enrollment process. These conditions also suggest that men of color will need targeted assistance to ensure that enough sign up for insurance coverage to reduce historical racial disparities in health care access and improve health outcomes. Page 3

4 RECOMMENDATIONS ON OUTREACH AND ENROLLMENT STRATEGIES Recommendations for community based groups Outreach and personalized assistance from trusted sources have been shown to boost enrollment rates in numerous public health insurance programs. 12 The In-Person Assister program established by Access Health CT provides opportunities for staff of grassroots community organizations to become certified Assisters in the enrollment process. Assisters will be trained on the enrollment procedures and health insurance options available through the ACA in Connecticut and will be involved in education, outreach, and enrollment efforts in their communities. Navigator organizations will coordinate and support Assister efforts. These programs are following best practice by focusing on personal assistance to enrollees, reaching out to community-based groups and local enterprises that serve men of color and have strong foundations in a neighborhood, and targeting neighborhoods with high concentrations of uninsured individuals. Nevertheless, community outreach and enrollment efforts need to be on-going and widespread and involve others beyond the cadre of officially certified Assisters. Community members need to be pro-active in their outreach efforts and target places where men of color are most likely to be present in significant numbers as venues for disseminating information about the ACA, health insurance, and health care. These locations might include, for example: Churches and faith-based organizations Affinity/associational groups of all types: immigrant associations, college fraternities, sports leagues Pharmacies, recreational centers, gyms, and barbershops Ethnic restaurants and grocery stores Soup kitchens, food pantries, homeless shelters Community groups will not have the detailed information that trained Assisters will have. But they can do a lot to inform people, raise their interest in health insurance and health care, and refer them to others who can give them more specific help. Community groups can also help to craft effective outreach and informational messages for men of color. Family members, spouses, partners, and friends are also important in getting the message to men and encouraging them to enroll in health insurance or Medicaid and seek health care once they have coverage. Evidence about the effectiveness of media efforts and public education campaigns alone is mixed, but it is clear that more targeted and personalized outreach and enrollment efforts can be very effective. 13 Page 4

5 Community groups can: Send as many staff and volunteers as possible to the training opportunities available to community members through the Navigator and In-Person Assister Programs. Make additional efforts to inform their staff, members, and volunteers about the ACA and encourage them to spread the word about the ACA. Use informal conversations, public events, social hours, meetings, newsletters, and other opportunities to provide information about the ACA to community members and encourage men of color to enroll in health insurance, utilize health care, and engage in healthy life styles. Provide information about the ACA in the languages community members speak and read. Refer individuals who have more questions to others such as local Assisters who can give them more specific information and assistance. Encourage their female members to spread information about the ACA s enrollment options and urge the men in their lives to sign up for insurance coverage and utilize health services. Recommendations for non-profit service providers Poor health affects so many aspects of a person s life - employment, education, housing, parenting and so many other aspects of life affect a person s health status, that client health should be a concern for all service providers who work with low-income men of color. It would be beneficial for these organizations to provide information about the ACA to their clients, encourage them to enroll in health insurance, and urge them to seek health care for their medical needs. Given the very high incarceration rates of African American males, non-profit organizations that work with the reentry population can be critical sources of information about health care and enrollment under the ACA. Since many young men of color are noncustodial, single parents, local fatherhood programs can be important points of contact. Community based programs that work on adolescent health issues, mental health, and substance abuse can also play a critical outreach role. Page 5

6 Staff at non-profit service providers can: Familiarize themselves with the provisions of the ACA and what is required to enroll in Medicaid or a plan available in the Access Health CT market. Discuss the importance of healthcare with their clients and encourage them to enroll in a health insurance plan. Know who the local Assisters and Navigators are and refer clients to them for more detailed information about enrollment and insurance choices. Post information about the ACA in waiting rooms and offices and provide written materials that explain enrollment procedures and eligibility criteria for expanded Medicaid and subsidized care through Access Health CT. Provide information about the ACA in the languages clients speak and read. Encourage their female clients to talk with their male friends, partners, family members, and relatives about the ACA and healthcare and encourage them to enroll in a plan. Co-ordinate dissemination strategies and share information with other non-profit organizations that work with men of color. Recommendations for community health centers Community-based health centers are a key source of health care for communities of color. They can also play a critical role in ensuring that people who are eligible for public health insurance receive and maintain coverage. Research shows when health centers invest in outreach they benefit financially from having more patients covered by health insurance and patients benefit from having continuous access to care and coverage. 14 To facilitate enrollment of men of color in Medicaid or a plan offered by Access Health CT, community health centers can: 15 Invest in outreach: Designate outreach staff to actively reach out to and engage uninsured individuals, enroll them in health coverage, and maintain eligibility for those already enrolled. Map areas with high concentrations of uninsured and Medicaid enrollees, and target outreach and enrollment efforts to these areas. Train health center workers in application procedures and outreach techniques, and provide them with eligibility screening tools, promotional materials, and policy-related information. Research the communities in which they are working and build relationships with communitybased organizations, faith-based organizations, local resident associations, and other key groups. Build eligibility screening into all center functions, including patient care, billing, translation services, and transportation services. Page 6

7 Recommendations for Access Health CT and the Connecticut Office of the Healthcare Advocate To maximize enrollment in health insurance among men of color, Health Access CT and the Connecticut Office of the Healthcare Advocate can support a broad array of outreach efforts that go beyond funding and supporting the work of the Assisters and Navigators during the initial open-entry period. Access Health CT and the Connecticut Office of the Healthcare Advocate could, for example: Find additional financial resources to keep Navigator and In-Person Assister programs operating after the initial open-entry period. 16 Develop and widely distribute informational posters and handouts to other community groups and service providers who are deeply grounded in communities and work with men of color. Provide training on the ACA to a broad range of service providers and community organizations, beyond the Assisters and Navigators, so their staff and members understand the ACA and how it is likely to impact their clients and members. Target special outreach efforts and informational materials to communities with high rates of uninsurance and to particularly vulnerable populations such as those with mental illness or substance abuse issues, and the homeless. Recommendations for the Connecticut Department of Social Services (DSS) Other state agencies play a critical role in setting policy and administrative procedures that affect enrollment in public health benefits and Connecticut s new Health Exchange. To facilitate the enrollment of men of color, the Connecticut Department of Social Services (DSS) could: Take advantage of federal opportunities that allow automatic or simplified enrollment in Medicaid for certain groups, such as recipients of the Supplemental Nutrition Assistance Program (SNAP) and parents with children enrolled in Medicaid/Husky A & B (Children s Health Insurance Program). These options are time limited, and states must submit waiver applications to utilize them. 17 Simplify eligibility and recertification procedures as much as possible and allow automatic enrollment whenever possible. Have DSS eligibility workers available in community health centers to enroll patients in public healthcare benefits. Work to strengthen cross-agency connections and coordinate policies and practices to ease barriers to enrollment. For example: Work with the Department of Corrections to enroll men in health insurance when they leave the criminal justice system. Page 7

8 THE CONTINUING CHALLENGE: KEEPING MEN OF COLOR ELIGIBLE AND ENROLLED IN HEALTH INSURANCE The challenge is not just getting men of color enrolled in Medicaid or private health insurance, but also maintaining their eligibility once they are enrolled. It s important to reduce the churning that occurs when individuals cycle on and off insurance. In the Medicaid system, this can happen because of fluctuations in income or failure to comply with administrative requirements such as notifying staff about changes in status or sending forms in on time. Even a temporary loss of coverage can cause low-income patients to delay or forgo necessary health services or seek care only in emergency situations. 18 Recommendations for community health centers and community based-organizations These organizations can take a number of simple actions to help their clients and patients maintain eligibility for public health insurance. Community health centers and other community-based organizations can: 19 Add a tickler or alert to the patient s/client s file. Automatically send a reminder postcard, , or text message close to renewal time and include consumer assistance contact information. Place apply and renew posters in public waiting spaces. Include information to connect people to outreach and eligibility workers. Call patients/clients and remind them to renew. Make special efforts to keep particularly vulnerable populations, such as individuals with mental health or substance abuse problems, aware of eligibility requirements and the consequences of not responding. The health problems and frequent changes in address that are typical of this population can make it difficult for them to receive notifications or submit forms and documentation within a short time frame. 20 Recommendations for the Department of Social Services Administrative regulations and practices can make it difficult for Medicaid beneficiaries to maintain eligibility over time. Seemingly small scale changes in enrollment rules can have a large impact on actual enrollment. For example, when Texas required enrollees in the State Children s Health Insurance Program (SCHIP) to renew eligibility every six months instead of every 12 months, enrollment dropped substantially. In contrast, when Georgia allowed on-line applications and loosened renewal requirements, enrollment increased. 21 Easing requirements and lengthening the certification period can also ease the administrative burden of processing applications. 22 Page 8

9 To reduce churning, the Connecticut Department of Social Services can: Utilize the new federal option that allows states to guarantee adults 12 months of coverage regardless of income fluctuations. 23 Simplify recertification policies and procedures as well as eligibility policies and procedures. Make special efforts to keep particularly vulnerable populations, such as individuals with mental health or substance abuse problems, enrolled. For example, develop an income change calculation and notification policy that is designed to maximize continuity in coverage and minimize unnecessary enrollee response requirements. Develop customized enrollment and recertification training for providers that serve behavioral health patients who are not insured. 24 CONCLUSION Reducing racial health disparities is one of the ACA s explicit goals. Race is an important factor that affects the likelihood of having health insurance and seeking care outside of emergency rooms. Lack of health insurance is not the only reason for health disparities, but it is a critical component in addressing them. Ensuring that men of color are enrolled in health insurance in Connecticut will take the combined efforts of many organizations working at a number of levels. It will require outreach efforts that are intentional, widespread, and targeted specifically to this demographic group. Page 9

10 Endnotes 1 USA Life Expectancy, accessed June 28, 2013, These data are for The Henry J. Kaiser Family Foundation, Connecticut: Men s Health Disparities, State Health Facts, accessed June 14, 2013, These data are from The Henry J. Kaiser Family Foundation, Connecticut: Men s Health Disparities. 4 Center on Budget and Policy Priorities, How Would the Medicaid Expansion Affect Connecticut? (Washington, DC: Center on Budget and Policy Priorities, n.d.). 5 Kaiser Commission on Medicaid and the Uninsured, Characteristics of Uninsured Low-Income Adults (Washington, D.C.: The Henry J. Kaiser Family Foundation, 2012), Table 2. 6 Center on Budget and Policy Priorities, How Would the Medicaid Expansion Affect Connecticut?, n.d. 7 Mark Abraham, Barriers to Minority Health in Bridgeport, A Review of Data on the Health of African American Males in Bridgeport and Connecticut Urban Areas (paper prepared for the Aspen Institute, 2013). 8 Abraham, Barriers to Minority Health in Bridgeport, The Henry J. Kaiser Family Foundation, Connecticut: Men s Health Disparities. 10 On the special challenges of insuring and keeping individuals with behavioral health issues insured in Massachusetts, see the Substance Abuse and Mental Health Services Administration s draft report Enrollment and Disenrollment in Subsidized Health Insurance: Lessons Learned in Massachusetts (Rockville, MD: Substance Abuse and Mental Health Services Administration, n.d.). 11 Angela Kimball et al., Medicaid Expansion and Mental Health Care (Arlington: National Alliance on Mental Illness, May 2013). 12 Sara Kliff, Open Enrollment, Newsweek, March 28, 2010; Laura Summer and Jennifer Thompson, Best Practices to Improve Take-Up Rates in Health Insurance Programs (Washington, D.C.: Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, 2008); Victoria Wachino and Alice Weiss, Maximizing Kids Enrollment in Medicaid and SCHIP: What Works in Reaching, Enrolling and Retaining Eligible Children (Washington, D.C.: National Academy for State Health Policy, 2009). 13 Wachino and Weiss, Maximizing Kids Enrollment in Medicaid and SCHIP, Jessica Kendall and Jennifer Sullivan, Best Practices in Outreach and Enrollment for Health Centers (Washington, DC: Enroll America s Best Practices Institute, 2012). 15 These recommendations are based on Kendall and Sullivan, Best Practices in Outreach and Enrollment for Health Centers, This was done to good effect in Massachusetts health reform effort. See Sharon K. Long, What Is the Evidence on Health Reform in Massachusetts and How Might the Lessons from Massachusetts Apply to National Health Reform? Timely Analysis of Immediate Health Policy Issues (Robert Wood Johnson Foundation and The Urban Institute, 2010); Alan G. Raymond, Massachusetts Health Reform: A Five-Year Progress Report (Boston: Massachusetts Blue Cross Blue Shield Foundation, 2011). 17 Health Policy Hub, Making Medicaid Enrollment Easier for People and for States, accessed May 20, 2013, blog.communitycatalyst.org. 18 Kendall and Sullivan, Best Practices in Outreach and Enrollment for Health Centers, Page 10

12 The Aspen Institute Roundtable on Community Change 477 Madison Avenue Suite 730 New York, NY The Aspen Institute Roundtable on Community Change distills lessons about how to revitalize distressed communities and helps policymakers, practitioners, and funders develop and implement effective strategies for promoting vibrant, racially equitable communities in the United States and internationally. and Mount Aery Development Corporation 73 Frank Street Bridgeport, CT Mission: To foster partnerships within Bridgeport Community and throughout the state of Connecticut to promote growth and awareness in the areas of education, social concerns, housing and health.

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